© Borgis - New Medicine 4/2011, s. 122-124
Małgorzata Dębska, *Eliza Brożek-Mądry, Anna Gorzelnik, Monika Jabłońska-Jesionowska, Mieczysław Chmielik
Management of the parapharyngeal space infection – diagnostic and therapeutic issues
Department of Pediatric Otolaryngology, Medical University of Warsaw, Poland
Head of Department: Prof. Mieczysław Chmielik, MD, PhD
Introduction: Pathology leading to infection in the parapharyngeal space is associated with different conditions beginning with upper respiratory tract infections. Therapeutic possibilities include conservative (pharmacological) and surgical treatment.
Aim: The aim of the presented study was to analyze the management of parapharyngeal space infections in our department.
Material and methods: The group of children who underwent conservative, pharmacological treatment included three boys at age 7, 12 and 14 months and two girls at age 18 months and 12 years. Surgical drainage was performed in three girls at age 3 (2 patients) and 12 years.
Results: Patients treated only pharmacologically did not meet any complications or relapse of the disease.
Conclusions: Conservative treatment can be applied in patients without complications threatening patients’ life, when improvement of the general condition is observed with normalization of the body temperature and reduction of inflammatory parameters in 24-48 hours.
Pathology leading to infection in the parapharyngeal space is associated with different conditions beginning with upper respiratory tract infections and otitis media through posttraumatic changes including foreign bodies and frequently forgotten tuberculosis. However, most cases are strictly connected with cervical lymphadenitis (1). Parapharyngeal space infections may have a fatal course due to respiratory distress or spread of the infection to other areas.
Therapeutic possibilities in parapharyngeal space pathology refer to anatomic division of the discussed space into prestyloid compartment containing mainly fatty tissue and retrostyloid compartment with neuro-vascular bundle. Infection in the prestyloid compartment may lead to liquefaction of the fatty tissue and pus formation that can easily penetrate in loose fibrous tissue to adhering spaces. Such location of the disease requires surgical drainage. On the other hand inflammation in the retrostyloid compartment is mainly connected with lymphadenitis and their fibrous capsule serves a better separation from surrounding tissues allowing introducing pharmacological treatment and watchful observation. Surgical treatment of retrostyloid abscess is reserved for patients in poor general condition, patients with respiratory distress due to mass effect and if there is no improvement after intravenous antibiotic therapy (1).
The aim of the presented study was to analyze the management of parapharyngeal space infections in our department.
MATERIAL AND METHOD
A retrospective analysis was conducted including eight patients diagnosed and treated in Pediatric Otolaryngology Department of Warsaw Medical University between 2005 and 2010 due to infection of the parapharyngeal space. The group of children who underwent conservative, pharmacological treatment included three boys at age 7, 12 and 14 months and two girls at age 18 months and 12 years. Surgical drainage was performed in three girls at age 3 (2 patients) and 12 years.
Patients treated pharmacologically presented following symptoms prior to admission: upper respiratory tract infection accompanied by temperature approx. 38°C for 4-6 days, anorexia and dysphagia, irritability and anxiousness. Patients’ history also revealed prior treatment with amoxicillin or fespiride. Physical examination performed at admission showed lymph nodes enlargement in all patients, impaired cervical mobility in two cases, trismus in one patient, enlargement and significant medial displacement of palatine tonsil on one side in four patients and ptosis on the contralateral side in one patient. Laboratory testing on admission showed elevated white blood cells count (19.7-40.2 x 103/mm3), elevated inflammatory parameters: C-reactive protein at level 8.5-53 mg/dl, erythrocyte sedimentation (ES) at 42-88 mm/h and anemia in four younger patients.
All patients underwent differential diagnosis towards toxoplasmosis, mononucleosis, cytomegaly and boreliosis and showed negative results. The diagnostic path reached radiologic tools such as computed tomography with contrast and magnetic resonance imaging and also ultrasonography was performed repeatedly to monitor the course of disease. Contrasted computed tomography in one patient showed well separated fluid compartment sized 12 x 12 mm with inflammatory oedema and the abscess was observed medially and anteriorly to the neuro-vascular bundle, in another patient the area pathologically changed sized 26 x 26 mm in parapharyngeal space. Magnetic resonance performed in one patient revealed pathologically changed lymph node located between antero-medial wall of internal carotid artery and capitis longus muscle, surrounded with the fluid margin. The last two patients were followed just with ultrasonography.
Pharmacological treatment was supplied intravenously with combined antibiotic therapy. Conjugated therapy included beta lactam antibiotics and lincosamides. Two patients received ceftriaxone, one patient cefotaxime, one patient cefuroxime, and one patient amoxicillin with clavulonic acid; additionally all patients received clindamycin. Hospital stay and intravenous treatment lasted 10-14 days until the symptoms withdrew and the normalization of laboratory testing was accomplished. Oral antibiotic treatment was continued until the regress of inflammatory changes in the parapharygeal space in ultrasonography was observed. Patients treated only pharmacologically did not meet any complications or relapse of the disease.
Patients treated surgically presented with different length of disease prior to admission to the Department and oscillated between few days and few weeks. Among reported symptoms there were upper respiratory tract infection with temperature to 39°C and cervical lymph nodes enlargement.
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